Howard J. Luks, MD



[pic] KNEE

Division of Sports Medicine

Howard Luks, M.D.

Chief

Patient Intake Form

Name _____________________________________________________ Date _____________________

Occupation ________________________________________________ Age _____________________

1) Who sent you to see us? Name _____________________________________________________

Address _________________________________________________ Phone ___________________

2) Who is your Internist or Primary Care Physician?

Full Name _______________________________________________ Phone ___________________

Address ____________________________________________________________________________

City, State, Zip ______________________________________________________________________

3) Chief Complaint/Current Illness:

a) Is your problem in the: Right Knee Left Knee

b) What is your chief complaint? ____________________________________________________

_________________________________________________________________________________

c) How long have you had this problem? ____________________________________________

d) Is your problem getting: Worse Better Staying the same

e) Was this a result of an injury? Yes No

If yes, please describe how it happened: ________________________________________

_________________________________________________________________________________

If yes, is this a worker’s compensation injury? Yes No (if no, advance to question #5)

4) Work-Related Injury:

a) Job title: ________________________________________________________________________

b) How long have you worked for this employer? ____________________________________

c) Date of injury: ___________________________

d) Are you: off work modified duty full duty

e) If you are not working full duty, what date did you last do so: _____________________

5) If PAIN is one of your complaints, please complete the following questions. If not, advance to Question #6.

Is your pain located in the:

Front Back Inside surface of knee Outside surface of knee œ Behind kneecap

b) Rate the average intensity of your pain/discomfort. (0=no pain, 10=severe pain)

0 1 2 3 4 5 6 7 8 9 10

c) Describe your Pain: Intermittent Constant

Dull Sharp Throbbing

Tight Burning Tingling

6) Timing

1) Is your pain worse at any particular time of the day? Morning Evening Night

2) Does your knee allow you to sleep comfortably? Yes No

7) Activity-Related Symptoms:

1) Is your knee comfortable at rest? ÿYes ÿNo

2) Can you walk without using supports (brace, crutches, cane, etc.)? ÿYes ÿNo

3) Can you walk without a limp? ÿYes ÿNo

4) Can you walk without your knee locking or catching? ÿYes ÿNo

5) Can you walk up one flight of stairs? ÿYes ÿNo

6) Can you walk up five flights of stairs? ÿYes ÿNo

7) Can you run the length of one block? ÿYes ÿNo

8) Can you run one mile? ÿYes ÿNo

9) Does your knee allow you to pivot, change directions, or jump

without “giving way”? ÿYes ÿNo

10) Does your knee allow you to perform your normal activities of daily living

(other than work or sport)? ÿYes ÿNo

11) Does your knee allow you to participate in sports? ÿYes ÿNo

12) Can you participate in sports at the level of competition you desire? ÿYes ÿNo

13) Does your knee allow you to work full-time at your job? ÿYes ÿNo

8) Do you ever have any of these additional symptoms?

YES NO If yes, describe

Stiffness ______________________________________________________

Numbness ______________________________________________________

Swelling ______________________________________________________

Instability ______________________________________________________

Weakness ______________________________________________________

Painful ______________________________________________________

Roughness ______________________________________________________

Other ______________________________________________________

9) Have you tried any of the below? Relief of Symptoms?

YES NO

Medication Type: _________________________________________________

Physical If yes, how long did you attend? _______________________

Therapy When was your last session? ___________________________

Injections If yes, where were they? _______________________________

Other Describe: _____________________________________________

10) Please list all medications you currently use with dosage and frequency: ____________________________________________________________________________________

____________________________________________________________________________________

11) Do you have any allergies? ÿYes ÿNo If yes, please list __________________________

____________________________________________________________________________________

12) Are you currently or have you ever had problems with the following:

YES NO Describe all “YES” responses

Heart Problem _______________________________________________

Breathing, Lungs ÿ _______________________________________________

High Blood Pressure _______________________________________________

Cancer _______________________________________________

Diabetes _______________________________________________

Arthritis _______________________________________________

Hepatitis, Aids, TB _______________________________________________

Liver problems _______________________________________________

Polio _______________________________________________

Epilepsy or seizures _______________________________________________

Bowls or colon _______________________________________________

Bladder problem _______________________________________________

Kidney problem _______________________________________________

Balance problem _______________________________________________

Numbness or tingling _______________________________________________

Blackout or fainting _______________________________________________

13) Please list all past surgeries and hospitalization:

Surgery/hospitalization Date Physician

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

14) Have you ever had problems with general anesthesia? YES NO

15) Do you drink alcohol? YES NO If yes, how much per week? __________________

16) Do you smoke? YES NO If yes, how much per week? ________________________

How long have you smoked? ____________________

17) Marital Status: Single Married Divorced/Separated Widowed

18) Do you:

YES NO

Have children How many _____________________________________

Live alone If no, with whom ________________________________

Use a special diet Describe _______________________________________

Use recreational drugs Describe _______________________________________

Exercise regularly How often _____________________________________

19) Sports/Hobbies: ____________________________________________________________________

20) Family History

Member Alive Deceased Age Health Status Cause of Death

Father _______ ___________ ______ _______________ ________________________

Mother _______ ___________ ______ _______________ ________________________

Sibling _______ ___________ ______ _______________ ________________________

Sibling _______ ___________ ______ _______________ ________________________

Sibling _______ ___________ ______ _______________ ________________________

21) How tall are you? _________________ How much do you weigh? __________________

Patient Signature______________________________________________ Date ________________

Thank you for taking the time to complete this information!

Reviewed by: _______________________________ Date: ________________

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